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An Integrative Model for Treatment of Sexual Desire Disorders

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An Integrative Model for Treatment of Sexual Desire Disorders INTEGRATIVE MODEL 1 An Integrative Model for Treatment of Sexual Desire Disorders: An Update of the Masters and Johnson Institute Approach Mark F. Schwartz Stephen Southern Harmony Place Monterey Author Note Mark F. Schwartz, Clinic Director, Harmony Place Monterey, and Stephen Southern, Clinical Consultant, Harmony Place Monterey Correspondence concerning this article should be addressed to Mark F. Schwartz, Harmony Place Monterey 398 Foam Street, Suite 200, Monterey, CA 93940. Email: [email protected] INTEGRATIVE MODEL 2 Abstract An integrative model for treating sexual desire disorders was developed from the original work of Masters and Johnson Institute. Sensate focus exercises and psychoeducation were combined with couple therapy for relationship conflicts and individual therapies for issues with trauma and attachment disorders. The resulting model fits trends in systemic and integrative treatment. Keywords: sexual desire disorders, hypoactive sexual desire, Masters and Johnson Institute, integrative treatment, sensate focus, couple therapy INTEGRATIVE MODEL 3 An Integrative Model for Treatment of Sexual Desire Disorders: An Update of the Masters and Johnson Institute Approach Masters and Johnson (1966, 1970) wrote very little about their approach to desire phase disorders. The lnstitute's conceptual approach to inhibited sexual desire focused on the relationship. As we mature, sexual response is a natural manifestation of attraction to a person perceived as appealing. This attraction evolves into a casual or committed relationship. Once a pair-bond is established, sexual desire is a natural way of expressing the sense of intimacy that develops within a committed relationship. Therefore, anything that enhances or inhibits relational intimacy may positively or negatively influence the individual's levels of sexual desire. Sex is innately pleasurable - unless something mitigates that pleasure. Couples who evidence little intimacy in the living room usually will feel distant from each other in the bedroom. Therefore, persons who are bored, pressured, fatigued, angry, guilty, fearful, anxious, or suffocated in a relationship are 'entitled' to low levels of sexual desire (Schwartz & Masters, 1988, p. 229) Thus, the Institute's approach to treating inhibited sexual desire was similar to their treatment of sexual dysfunction. The relationship was the primary focus of treatment rather than the symptomology. An update on Masters and Johnson Institute’s model for treating sexual desire disorders takes into account the primacy of the couple’s relationship, since there is a connection to intimacy, as well as roadblocks or constraints that may be individual in origin. An integrative model for treating sexual desire disorders balances individual and couple issues. INTEGRATIVE MODEL 4 Sexual Desire Disorders Desire disorders include Female Sexual Interest/Arousal Disorder (302.72) and Male Hypoactive Sexual Desire Disorder (302.71) in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-V; American Psychiatric Association, 2013, pp. 433- 436; 440-443). There is a broader range of dysfunctions and dissatisfactions that may be considered desire disorders by experts in sexuality therapy (Kaplan, 1995; Leiblum, 2010). For the purpose of this review, desire disorders include low sexual desire or interest within an individual or between partners in a sexual relationship. There are many theories that account for lack or loss of desire including biological, developmental, intrapsychic, relational, and cultural factors. While desire discrepancy in a couple, in which one partner presents lower desire than the other, is not sufficient to diagnose a sexual problem (e.g., APA, 2013, p. 433), such differences are frequently presented in couple counseling. Discrepancies arise as the sexual relationship is affected by a myriad of nonsexual issues or intimacy dysfunction in general. Female Sexual Interest/Arousal Disorder Female Sexual Interest/Arousal Disorder blurs phases of interest and arousal according to the classic model of the sexual response cycle (Kaplan, 1974, 1979; Masters & Johnson, 1966, 1970). Low sexual desire in this context may be presented as lack of interest in sexual activity, absence of erotic or sexual thoughts, reluctance to initiate sex, and inability to respond to a partner’s sexual invitations (APA, 2013, p. 433). Female sexual interest/arousal disorder may be lifelong or acquired; generalized or situational; and ranging from mild to moderate or severe distress. Symptoms must have persisted for at least six months duration. The symptoms cannot be better explained by a nonsexual medical or mental condition or by INTEGRATIVE MODEL 5 severe relationship distress such as partner violence. At least three of the following characteristics are required for diagnosis of the disorder (APA, 2013, p. 433). 1. Absent/reduced interest in sexual activity. 2. Absent/reduced sexual/erotic thoughts or fantasies. 3. No/reduced initiation of sexual activity, and typically unresponsive to a partner’s attempts to initiate. 4. Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (approximately 75-100%) sexual encounters (in identified situational contexts or, if generalized, in all contexts). 5. Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (e.g., written, verbal, visual). 6. Absent/reduced genital or nongenital sensations during sexual activity in almost or all (approximately 75-100%) sexual encounters (in identified situational contexts or, if generalized, in all contexts). Female sexual interest/arousal disorder replaced “hypoactive sexual desire disorder” from the previous DSM because problems with sexual desire and arousal frequently coexist and may reflect difficulty or inability to identify cues for sexual opportunity, including physical changes in the woman’s body. While there are changes in sexual interest and arousal across the lifespan, sexual desire may decrease with aging. The lack or loss of desire is not necessarily reflected in frequency of sexual activities such as intercourse. Vaginal dryness and genito-pelvic pain constitute other sexual disorders or physical conditions. Comorbidity with other sexual dysfunctions is INTEGRATIVE MODEL 6 common. Prevalence and incidence data were not reported in the DSM-V because of the novelty of the consensus-based diagnosis. (p. 435). Male Hypoactive Sexual Desire Disorder Male Hypoactive Sexual Desire Disorder (APA, 2013, pp.440-443) remains distinct from arousal/excitement and orgasm/ejaculation. The disorder shares criteria with female sexual interest/arousal disorder: at least 6 months duration; lifelong vs. acquired; generalized vs. situational; and mild-moderate-severe distress. The major diagnostic feature places hypoactive sexual desire in context. Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity. The judgment of deficiency is made by the clinician, taking into account factors that affect sexual functioning, such as age and general and sociocultural contexts of the individual’s life (APA, 2013, p. 440). Prevalence of male hypoactive sexual desire disorder varies from 6% in younger men (18-24 years of age) to 41% of older men (66-74 years); however, persistent lack of interest in sex affects only 1.8% of men ages 16-44 (p. 442). Both male hypoactive sexual desire disorder and female sexual interest/arousal disorder, were associated with five conditions in the DSM-V (APA, 2013) 1. Partner factors (e.g., partner’s sexual problems, partner’s health status); 2. Relationship factors (poor communication, desire discrepancies); 3. Individual vulnerability factors (poor body image, history of sexual or emotional abuse) and/or psychiatric comorbidity (depression, anxiety) or stressors (job loss, bereavement); INTEGRATIVE MODEL 7 4. Cultural/religious factors (attitudes, inhibitions or prohibitions against sexual activity); and 5. Medical factors (including effects of medication). Temperament, environment, genetic predisposition, substance/medication use, and other sexual dysfunctions contribute to the emergence and maintenance of these sexual desire disorders. There are obvious gender differences in the contributing factors and presentations of the disorders. Recent Models of Sexual Desire Disorders Leiblum (2010) edited an authoritative text on the clinical manifestations of sexual desire disorders. In one of the last contributions to her brilliant career, she provided an overview of the field. Sexual desire is the most elusive of passions. While easily ignited in a new relationship or a forbidden encounter, it can also be readily extinguished. Anxiety, hostility, bad memories, or frightening flashbacks can thwart it-even something simple as the sound of a door opening or a child crying. And yet, when aroused by an image or scent or fantasy or person, it can feel powerfully intense, driven, lively, and life affirming (Leiblum, 2010, p. 1). Leiblum and colleagues traced sexual desire from libido to social construction, carefully examining cultural and gender issues involved in sustaining just the right amount of desire to facilitate bonding in an intimate relationship. She reported prevalence rates ranging from 8% to 55% in studies of women and men across the age spectrum (Leiblum, 2010, p. 9). Interestingly, while 45% of women identified low sexual desire in a survey of sexual dysfunctions, only 16% reported distress with
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